New Patient Registration

Please complete our online form

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Patient's Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

In order to provide safe and effective patient care it is imperative that this form is completed in full.

Have you been registered at Tisbury Surgery previously?: *

Sex: *

Is your gender the same as that with which you were assigned at birth::

Ethnicity

Please specify the ethnic group you consider you belong to: *

Contact Details

Preferred Contact Number: *

Consent – please tick EACH applicable box to indicate your consent for the practice to contact you: *

Do you give us permission to leave voicemail messages on your phone(s)? Please tick for yes. : *

Please note that you may withdraw consent for the surgery to contact you at any time. Please contact us if you wish to amend your consent.

Veterans

Are you a military veteran?: *

Previous Address

Are you from abroad or have lived overseas?: *

Next Of Kin

Nominating Others

If you are happy to give permission to share information, discuss your care or give test results to someone else , please give us their name and relationship to you.
You can change this information or permission at any time

Nominated Pharmacy

Tick one:

Walking Independently

Are you able to walk independently?: *

If not please tick which of the following best corresponds to you.:

Carers

Is there someone who relies on you so much that you would need to organise backup if you went away for a day or two? If so, then YOU ARE A CARER

Do you have a carer or are you a carer? (Even if the person you care for is not a patient at this surgery): *

If you tick “yes” our carer’s lead will contact you shortly to gather some further information to ensure we are supporting you as best we can.

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Medical History

Do you have any allergies? : *

Female and Previously Female Only

Have you had a hysterectomy?:

If yes, do you still have your cervix?:

Communication Needs

Do you have any communication difficulties e.g, hard of hearing, need a translation service, learning difficulties etc.):

How would you prefer us to communicate with you? (Tick as many as necessary) :

If you need anything that is not on the section above, please tell us and we will do our best to meet your needs

We regularly use SMS to confirm appointments, send messages about test results, inform you of upcoming health campaigns etc. However, there are certain conditions attached to the use of the service. Please read the statement below and should you wish to register for SMS Messaging, tick all statements to agree with the terms and sign the declaration at the bottom.

Lifestyle Questions

Have you ever smoked: *

Do you smoke currently?: *

How many cigarettes/cigars do you smoke a day?:

Would you like help to give up?:

Please complete the below alcohol consumption questionnaire

How often do you have a drink containing alcohol?: *

How many units of alcohol do you drink on a typical day when you are drinking? (see diagram above): *

How often have you had 6 or more units (females) or 8 or more units (males) on a single occasion in the last year?: *

One of the Practice Team may be in touch with you regarding your alcohol consumption. You can book in with one of our nurses or get more information about the risks of excessive drinking at

Book and manage your face-to-face GP appointments, request medication and update your personal details online

What is SystmOnline?

Web based
No app available
Book and manage face to face GP appointments
Order medication
View test results
View your record

What is Airmid?

App based
Book and manage face to face GP appointments
Order medication / change pharmacy / view electronic prescription
View test results
View your record
Send messages directly to a clinician
Use your existing NHS login to sign up
Video Consultations
Plus more

Online services are available 24hrs a day. You can book 2 future appointments with a GP which could save you a trip or phone call to the surgery. You can change your pharmacy and communicate directly with a clinician, but please bear in mind that a clinician will only respond during clinic opening times. This is a non urgent way to contact the practice. We aim to respond within 3-5 working days

How do I get access to the online services once I am fully registered at Tisbury Surgery?

If you have used SystmOnline previously, you can still use the same login details to access Airmid, downloadable from both the Apple App Store and Google Play
If you have not had SystmOnline before then Airmid allows you to use your NHS App Login to sign in.
For a new registration or if you don’t have the NHS App, you can come into the practice to complete an online access registration form.

Please bring identification with you for security reasons we need to confirm it is you. Alternatively, you can download a registration form from our website and bring it the surgery with identification

Sharing Your Information

National data sharing opt-out

You can choose whether your anonymised confidential patient information is used for research and planning. If you wish to opt out or find out more visit NHS: Your Data Matters

Summary Care Record (SCR) – sharing information with other healthcare providers

Many patients think that their GP record is available to any other clinicians that they may come into contact with, for example 111, A+E or the local hospitals. This is not the case and at present your GP medical record is kept within the Practice.

Essential details about your healthcare can be difficult to remember, particularly when you are unwell or have complex care needs. Having a Summary Care Record can help by providing healthcare staff treating you with vital information from your health record such as allergies. This will help the staff involved in your care make better and safer decisions about how best to treat you. Authorised healthcare staff can only view your SCR with your permission e.g. if you are being seen at the walk-in-centre. The information shared will solely be used for the benefit of your care. Please note that it is not compulsory for you to complete this form. If you choose not to complete this form, a Summary Care Record as per option (b) below will be created for you. Please tick your preference:

If you are filling out this form on behalf of another person, please ensure that you fill out their details above; you sign the form above and provide your details below:

Select one:

For more information visit NHS Digital or call 0300 303 5678. You are free to change your decision at any time.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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New Patient Registration

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